Category Archives: Tumors Of The Digestive System
What Is Pancreatic Cancer
Pancreatic cancer is a malignant growth in the glandular organ of the digestive system called pancreas.
- Vomiting, jaundice and pain at the back of the stomach are the symptoms of pancreatic cancer.
- CT scan helps diagnose cancer of the pancreas.
- Pancreatic cancer is a potentially fatal disease.
- Chronic inflammation of pancreas, diabetes and smoking increase the risk of developing pancreatic cancer.
- Surgical removal of the pancreas may result in complete cure in the early stages.
Pancreas is located at the curve of the duodenum, which is the first portion of the small intestine. The pancreatic duct drains into the duodenum, a little beyond the junction of the stomach and the small intestine. It is a glandular organ secreting both digestive enzymes and hormones. Adenocarcinomas originating from glandular cells constitute 95% of pancreatic cancer. Cancerous tumors of the pancreas develop on the lining of the pancreatic duct. The part of the pancreas joining the duodenum is called its head and most of the adenocarcinomas usually develop in this area.
Pancreatic cancer is the fourth among the most common causes of death due to cancer in the US and its incidence is steadily rising. Over thirty-seven thousand people, mostly over the age of 50, are diagnosed with the disease every year. In addition to age, smoking is another factor which predisposes people to pancreatic cancer. Incidence of cancer in smokers is two to three times more than that in non-smoking people. However, caffeine or alcohol does not seem to be increasing the risk of cancer. People who have had diabetes for a long time, especially women, have a higher risk. Pancreatitis is the inflammation of pancreas; people with this condition are also more prone to pancreatic cancer.
Symptoms
Symptoms of pancreatic cancer vary depending on the location and size of the tumor. The bile duct joins the pancreatic duct before it drains into the duodenum. If a large tumor develops in the pancreatic duct near its head, it may obstruct the passage of bile from the liver into the small intestine. This may result in jaundice, characterized by the yellowing of the eyes and the skin. It is one of the first symptoms of pancreatic cancer. Itching also may be present along with jaundice due to the presence of bile salt deposits in the skin. If the cancer causes obstruction in the small intestine, or if it blocks the passage of food from the stomach into the intestine, it may result in vomiting. If the tumor is located in the body of the pancreas or near its tail end, it may not cause any symptoms unless it is obstructing the vein which leads out of the spleen. The lack of symptoms often delays the detection of the disease till it spreads to other areas.
Complications: When adenocarcinoma develops in the tail end of the pancreas or in the main body of the organ, it may grow very large before symptoms appear. In the meantime, the cancer would have metastasized to other tissues and organs in most of the cases. Lungs, liver and the nearby lymph nodes, are the usual sites of metastasis. Pain in the upper part of the abdomen radiating towards the back, and noticeable weight loss, may be the first symptoms which alert people and their doctors to the possibility pancreatic cancer. However, by this time, the cancer would have reached a stage when it is no longer curable.
The spleen is an organ which is involved in the production and destruction of blood cells and it is located near the tail end of the pancreas. When a large adenocarcinoma at the tail end of the pancreas causes obstruction to the vein leaving the spleen, it results in splenomegaly or spleen enlargement. The veins around the stomach and the esophagus also may swell up to form varices. These varices, especially those around the esophagus, may rupture resulting in bleeding.
Diagnosis
Pancreatic cancers, especially those developing in the body of the pancreas or in the tail portion, are usually diagnosed very late due to the absence of symptoms during the early stages. Blood tests or a physical examination may not show any abnormality. Ultrasound scanning, MRI scans, and an endoscopic test called retrograde cholangiopancreatography, may help in diagnosis. However, the most reliable and accurate test for cancer of the pancreas is the CT scan or computed tomography.
A biopsy of the pancreatic tissue may be conducted to confirm the presence of cancer. The tissue sample may be obtained by drawing it out with a needle under the guidance of a CT scan or an ultra sound scan. But there is some risk involved, as there is a high chance of the procedure causing the spread of cancer into surrounding areas. Sometimes, a biopsy of the liver is done in the same way to detect the presence of cancer cells which may have spread to the liver from the pancreas. Surgical exploration of the pancreas is also considered when other non invasive tests fail to give conclusive evidence of the disease or the absence of it.
Prognosis and Treatment
Surgical removal of the pancreas (Whipple procedure), usually including the part of the duodenum where the pancreatic duct joins the intestine, may cure the disease when it is detected before the cancer has spread to other areas. But pancreatic cancer is rarely discovered early for surgery to be effective. Consequently, less than 20% of pancreatic cancer cases qualify for surgery (Whipple procedure), and among those who have undergone surgery too, more than 80% people succumb to the disease within five years. Radiation treatment and chemotherapy are also tried with or without surgery, but they do not contribute significantly to prolonging life. When the cancer has progressed to an advanced stage the focus shifts to the management of symptoms.
NSAIDs such as acetaminophen or aspirin may relieve pain in some cases. But more often, stronger pain relieving medication may be necessary. Oral administration of morphine or codeine may be tried if the pain is severe. But a majority of people with pancreatic cancer may need nerve blocks directly injected into the nerves to get real relief from extreme pain. Oral supplementation of pancreatic enzymes may have to be given to aid digestion, and insulin injections may be necessary, if the patient develops diabetes.
If there is obstruction to the flow of bile from the gall bladder into the small intestine due to the growth of a tumor near the head, a stent is inserted into the duct to drain the bile. If the tumor impedes the flow by blocking the duct again, a channel from the gall bladder to the intestine is created, bypassing the pancreatic duct. If the cancer causes intestinal obstruction, making a connection between stomach and the intestine at a point after the obstruction bypasses the affected part.
Since pancreatic cancer has very poor prognosis, especially when it is detected in an advanced stage, treatment options are few and the doctor may have to discuss palliative care options with the patient and family members. As a fatal outcome is almost certain, the patients and their families may be prepared for it in advance.
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Tumors Of the Pancreas (Pancreatic Neuroendocrine Tumors)
Pancreas is a glandular organ attached to the duodenum, which is the first portion of the small intestine. Pancreas has both exocrine and endocrine functions. While the exocrine gland cells produce the pancreatic juice which aids the digestion of food, the endocrine cells produce hormones. The tumors arising from the endocrine gland cells may be benign or malignant. Some may be functioning tumors secreting hormones; others may be nonfunctioning. Functioning tumors often result in syndromes caused by the overproduction of hormones. It is not just the malignant and functional tumors that cause problems; non functional benign tumors also can cause blockage in the small intestine or obstruction to the drainage of bile. They can cause bleeding too.
INSULINOMA
A pancreatic endocrine tumor that secretes the hormone insulin is called insulinoma. Lowering of the blood sugar level is the effect produced by the hormone insulin. Insulinomas are rare tumors and 90% of them are noncancerous.
Symptoms
The typical symptoms of insulinoma are the same symptoms produced by hypoglycemia or abnormally low blood sugar level. When a person has fasted for several hours, especially in the morning after a long night without food, weakness, sweating, palpitations and trembling may be felt. Extreme hunger, headache, vision problems, confusion and personality changes are also other symptoms. Hypoglycemia can cause seizures, fainting or even coma, if measures to elevate the blood sugar is not undertaken.
Diagnosis and Treatment
Diagnosing an insulinoma can be difficult by regular blood tests. High levels of insulin in the blood, with low levels of blood glucose, are indicative of insulinomas, but to determine the condition, the blood tests have to be conducted exactly when the patient displays the symptoms. Often, the patients are admitted in the hospital to artificially create conditions such as prolonged starvation, which produce the symptoms. The patient stays without food for 24 to 72 hours until symptoms appear, and then the blood glucose levels are measured. This test will help in ascertaining the presence of functioning insolinomas.
Once the presence of insulinoma is established through blood tests, the location of the tumor has to be identified. Ultra sonography tests with the ultra sound probe inserted into the intestine with the help of endoscope gives better images of the pancreatic tumors. Pet scans are also used for better imaging of the tumors, but occasionally, surgery may be required to find the tumor. If the tumor is found during exploratory surgery, it is removed immediately. If the tumor is completely removed, it cures the disease, but symptoms may continue with incomplete removal. Drugs such as diazoxide and Octreotide help in preventing acute hyperglycemia which may result from excess insulin production by the remaining tumor cells. Chemotherapy drugs streptozotocin and 5-fluorouracil are found to retard the growth of these tumors.
GASTRINOMA
An abnormal growth in the pancreas or the first part of the small intestine called duodenum may be a gastrinoma if it is secreting the hormone gastrin. The function of the hormone gastrin is to trigger the production of digestive enzymes and acids by the stomach. Overproduction of gastrin will result in the overproduction of digestive acids which in turn cause peptic ulcers.
gastrinomas usually occur in clusters, and in half the cases, they are malignant. They occur either inside the pancreas or very near it. A hereditary condition called multiple endocrine neoplasia predisposes people to the development of tumors from glandular tissue in various organs producing hormones. The pancreas which has special cells producing the hormone insulin is one such glandular organ usually affected by this inherited disorder.
Symptoms and Diagnosis
Zollinger-Ellison syndrome characterized by the occurrence of a severe form of peptic ulcer in the stomach and the small intestine is usually caused by the gastrinomas in the pancreas. Though a quarter of the Zollinger-Ellison syndrome cases may not have gastrinomas, doctors are alerted to the possibility of this tumor when they come across aggressive forms of peptic ulcers and when the ulcers do not respond to the usual treatments. Zollinger-Ellison syndrome is a potentially fatal condition which can cause intestinal bleeding, and rupture of the intestine. All the people with gastrinomas do not have Zollinger-Ellison syndrome; mild peptic ulcer and diarrhea may be the symptoms in half the cases.
Frequent incidence of peptic ulcer alerts a doctor to the possibility of gastrinoma. When the usual treatment for peptic ulcer is found to be ineffective also, gastrinoma is investigated. A test to detect the blood levels of gastrin is done. Abnormally high levels of gastrin will conclusively prove the presence of gastrinoma.
After gastrinoma is detected, imaging tests are conducted to detect its exact location. Ultrasound testing with the aid of endoscope, CT scan, and PET scan, are some of the tests available. An x-ray, taken after the injection of a radio opaque dye into the artery supplying the pancreas, also is a useful test to find the tumor. Gastrinomas are usually very small and hard to locate.
Treatment
Temporary relief from the distressing symptoms may be obtained by the use of proton pump inhibitors; but large doses may be needed. Removing the gastrinoma by surgery may cure the disease in 20% of cases. If the above treatments are not effective, total gastrectomy may be the only option, in which the entire stomach is surgically removed. The gastrin produced by the gastrinoma cannot influence the stomach glands to produce the peptic ulcer-causing stomach acids any more. Lifelong oral supplementation of calcium and iron, and B12 injections, are essential because those minerals and vitamins can no longer be obtained from food, when the digestive juices produced by the stomach are absent.
When the cancer has spread to tissues and organs elsewhere in the body, the patient is treated with chemotherapy, which may not cure the cancer, but may help in reducing the symptoms. It can retard the growth and spread of the tumor and reduce the gastrin production. Gastrinomas usually have a fatal outcome.
VIPOMA
A rare tumor of the pancreas producing a substance called vasoactive intestinal peptide, or VIP for short, is termed vipoma. The action of this peptide results in severe, chronic, diarrhea with thin, watery stools.
More than half to three quarters of the vipomas are malignant. People who have the inherited condition called multiple endocrine neoplasia have a higher chance of developing vipoma.
Symptoms
Severe diarrhea, producing one to three quarts (1liter to 3 liters) of stools, is the main symptom of vipoma. The watery diarrhea causes dehydration and fatigue. The severity of the symptom may vary from time to time, or constant diarrhea may be present.
Conditions such as hypokalemia and acidosis may develop, because the constant diarrhea results in the loss of potassium salts and makes the blood acidic. Abdominal cramps, nausea and vomiting, muscular weakness and lethargy are caused by the deficiency of minerals and vitamins.
Diagnosis and Treatment
The initial diagnosis is based on the symptoms described by the patient. If a blood test shows abnormally high levels of vasoactive intestinal peptide, it is conclusive proof of vipoma. When the disease is identified, imaging tests to locate the tumor are conducted. PET scan and endoscopic ultrasound scan may be able to locate the vipoma before surgery is done.
Rehydrating the patient and replenishing the body with all the minerals and salts lost through the constant watery diarrhea is the first challenge in treating the symptoms of vipoma. Oral rehydration preparations, as well as bicarbonates to prevent acidosis, are given. But since the diarrhea is almost constant, keeping up the rehydration regimen is also a constant battle.
Removing the tumor surgically is the best option. In the early stages, before the tumors have spread, surgery effectively cures the disease in half the cases of vipoma. Even after the tumors have spread, surgery may be done to get relief from the distressing symptoms. Chemotherapy offers no benefit in either curing the condition or in relieving the symptoms. Octreotide is an effective drug for reducing diarrhea, but only when it is administered in high doses.
GLUCAGONOMA
A functioning pancreatic tumor producing the hormone glucagon is termed glucagonoma. The overproduction of glucagon has the effect of elevating the blood sugar levels. A characteristic rash is also another symptom.
Glucagonomas are malignant in 80% of the cases, but since they are slow growing tumors, most people with the disease live for more than 15 years from the onset of symptoms. 80% of the cases are found in women. The symptoms of glucagonomas usually start appearing around the age of fifty.
Symptoms and Diagnosis
The overproduction of glucagon by the tumor causes the characteristic symptoms of Type II diabetes. Weight loss may be one of the first symptoms noticed. Another characteristic symptom found in 90% cases is a skin rash which is brownish red in color and causes scaling. It may start in the groin area and may affect forearms, legs and buttocks too. This condition is called necrolytic migratory erythema and it is often accompanied by other symptoms such as cracking at the corners of the mouth and a bright red tongue which may look smooth and shiny.
A blood test which detects abnormally high levels of the hormone glucagon in the blood is the conclusive evidence of the presence of glucagonoma. Once the tumor is confirmed, its location is determined by imaging tests such as CT scan and endoscopic ultrasound scan. If the tumor is not detected by CT scan, a PET scan or an MRI may be necessary.
Treatment
Surgical removal of the growth is the ideal treatment to get complete relief from symptoms. If the tumor is too widespread for effective surgical removal, chemotherapy may help reduce the symptoms produced by the overproduction of the hormone glucagon. Chemotherapy is neither a cure for the condition nor does it help in prolonging life. It is a temporary measure to alleviate the symptoms and ensure a better quality of life.
Blood levels of glucagon may be brought down by the drug octreotide which increases appetite, thereby helping in gaining weight. The rash also may disappear with this medication. But elevation of blood glucose levels is a side effect. Intravenous administration of fatty acids and amino acids and topical application of Zinc ointments are other treatments which may relieve the rash.
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What Is Anal Cancer
What Is Anal Cancer ? Anal cancer is a malignant growth arising from anus, the posterior opening of the digestive system. Cancer of the anus is different from the more frequently occurring colorectal cancer.
- Pain and bleeding from the anus, itching in the perianal area are the usual symptoms.
- Sexually transmitted infections like HPV and anal intercourse are risk factors.
- Anal cancer is diagnosed by a physical examination of the anus, and confirmed by biopsy.
- Surgery, chemotherapy and radiation therapy are the different treatment options, used singly, or more often, in combination.
Cancer of the anus is distinct from the more frequent colorectal cancers which are generally adenocarcinomas. On the other hand, squamous cell carcinomas are the most frequently occurring type of anal cancer. It usually originates in the skin surrounding the anus, or in the lining of the anal canal between the rectum and the anal opening. Sarcoma, lymphoma, melanoma and adenocarcinoma are some of the very rare forms of anal cancers.
Anal cancer is not as prevalent as colorectal cancer but over four thousand people in the US are diagnosed with the disease every year. The incidence is found to be more in women, almost double that of in men. The exact cause of the cancer of the anus is not known but certain factors are found to make people more prone to developing the disease. Among those who practice anal intercourse, the receptive partner is found to have a greater risk of cancer. Infections which are transmitted sexually, such as lymphogranuloma venerum and human papillomavirus-type 16, also predispose people to this disease.
Symptoms and Diagnosis
Pain and bleeding during bowel movements are the usual symptoms of anal cancer. Itching of the skin surrounding the anus also may be a symptom. One fourth of those who have cancer of the anus do not display any symptoms and the disease often goes unnoticed unless it is detected accidentally or by a routine physical examination.
A physical examination of the skin surrounding the anus helps the doctor find abnormalities which may suggest anal cancer. Doctors may be able to feel differences in the texture when the lining of the anal passage and the rectum are examined with a gloved finger. A biopsy may be done so that a portion of the lining may be examined in the laboratory for abnormalities.
Treatment
Surgical removal of the affected area usually cures the disease. But there is a high risk that the surgery may damage the muscular ring called anal sphincter, which keeps the anus closed except during a bowel movement. If anal sphincter is damaged during surgery, it will result in fecal incontinence. To avoid this situation, sometimes chemotherapy or radiation therapy, or a combination of both, may be considered instead of surgery. But when surgery is combined with either chemotherapy or radiotherapy, it gives the best results. In several cases of anal cancer, complete recovery is possible, and more than 70% of people with anal cancer survive beyond 5 years. Even after the treatment is complete, people should undergo periodic testing for anal cancer. If there are signs of recurrence detected during a routine testing, further surgery may be required.
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Colorectal Cancer
Cancer affecting the colon and the rectum are collectively known as colorectal cancer.
- Bleeding from the rectum and fatigue are the common symptoms of colorectal cancer
- Colorectal cancer in the early stage is curable
- Diagnosis is confirmed by a colonoscopy.
- People above the age of 50 should regularly undergo screening tests
- Hereditary factors and certain dietary habits predispose some people to this disease
- The main treatment is the surgical removal of cancer
Adenocarcinomas are the usual type of cancer found to affect the rectum and the large intestine. They originate either directly from the lining of the rectum and colon or from pre-existing colorectal polyps. The cancerous growths initially start as tiny mushroom-like outgrowths on the lining, but they soon grow into the wall of the colon and rectum. The cancer may spread to lymph nodes too. Colorectal cancer has a high probability of metastasizing to the liver as the blood flow from the intestinal wall continues to the liver.
Colorectal cancer is more prevalent in industrialized countries. For example, in Europe and the US, colon cancer and rectal cancer are among the most common cancers. They are also a leading cause of fatalities due to cancer. The incidence of colorectal cancer is found to vary according to age and gender. People above the age of 40 may start developing the disease but it is most prevalent in those above 60 years of age. Women are found to be more prone to it than men. Among the people who have colon cancer, a few may have it in more than one location independent of one another. Every year, around one hundred and fifty thousand people are diagnosed with bowel cancer in the United States alone and about one third of them succumb to the disease.
Risk Factors
Colorectal cancer seems to run in families. So, people who have one or more family members with the disease are at greater risk of this disease. Since colorectal polyps have a tendency to become malignant, people who already have familial adenomatous polyposis risk, also have a higher chance of colorectal cancer.
Crohn’s disease or ulcerative colitis is another risk factor that predisposes people to colon cancer. The longer a person has had the above conditions, the greater the risk.
Diet also is considered to play a role in the development of colorectal cancer. Diet high in fat and low in fiber content is a risk factor. The presence of carcinogens in the air and water, due to industrial pollution, also could be a reason for the greater incidence of colorectal cancer in the industrialized countries.
Some people have a mutated gene which predisposes them to early onset of colorectal cancer.70 to 80% of those who have inherited this mutated gene develop the disease even before they reach 50 years. This condition is known as HNPCC or Hereditary Non polyposis Colorectal Carcinoma. People with this gene have a higher risk of developing various other cancers of the digestive tract such as stomach cancer and cancer of the small intestine. They have a higher incidence of ovarian and endometrial cancers too.
Symptoms
Colorectal cancer remains asymptomatic for years as it is a slow growing cancer. Slight bleeding from the cancer results in occult blood in the stool, but it cannot be seen except in a lab test. Over a period, this continuous bleeding may result in fatigue and anemia. Some Patients may notice blood on toilet paper. Depending on the type of cancer, the stage it is in, and also the area affected, other symptoms start to appear.
When a tumor develops in the ascending colon on the right side, there may not be any symptoms as there is no chance of obstructions here. This part of the bowel is quite large in size and the stool passing through it is in liquid state. Usually, the cancer is not detected till the growth becomes large enough to be felt by the doctor during a routine abdominal examination.
On the other hand, if a tumor is present in the descending colon on the left side, obstructions usually occur. This part of the colon is smaller, and the stool is in a semisolid state as it passes here. Symptoms display an alternating pattern in bowel movements; high frequency of bowel movements for a period followed by a period of constipation. Abdominal cramps and pain are other symptoms which may be present along with severe constipation. They usually prompt people to get medical help, which often leads to the diagnosis of cancer.
Slow and steady bleeding from colon and rectal cancers are common, but sometimes, the blood may not be visible to people. A stool test for occult blood may detect the bleeding, but if the stool is blood stained, it may prompt people to see a doctor. It may result in early detection of the cancer as bleeding from rectum is the characteristic symptom of colorectal cancer. There are other abnormal conditions such as diverticulitis and hemorrhoids which have the same symptom of blood in the stool or blood on toilet paper. But when a person comes to the doctor with the complaint of bleeding from the rectum, it is mandatory to check for cancer. When a person feels incomplete emptying of the rectum immediately after a good bowel movement, it may be an indication of rectal cancer and has to be investigated without delay. People with cancer of the rectum may have pain during defecation, or when they sit, but the absence of such symptoms cannot rule out the presence of cancer.
Diagnosis
Screening Tests: Routine tests and screening for cancer is the best way to diagnose colorectal cancer. People who are at high risk of developing the disease should have periodic scanning. Occult blood test is done usually on a sample of stool collected after the patient is put on a meat-free diet for 3 days. Diet high in fiber is also recommended on these days to get an accurate result. Physical examination of the rectum with a gloved finger may help detect bleeding. If the doctor finds evidence of rectal bleeding, more tests are conducted to confirm the diagnosis.
For regular screening for colorectal cancer, a viewing test called sigmoidoscopy is employed. If abnormalities are detected, colonoscopy is done. Sometimes colonoscopy itself is used as a standard screening procedure, especially for people in the high risk category. The advantage of colonoscopy is that, in addition to the detection of cancer, some treatment procedures such as cauterization, or surgical removal of polyps and small tumors, also can be done during the procedure.
CT colonography, also called virtual colonoscopy is a CT scan procedure in which instead of the actual viewing of the colon, a small tube inserted into the colon to take very clear 3-d pictures of the intestine and the rectum. Prior to the test, a contrast agent is swallowed, and the colon is filled with gas to expand it for a clearer view. Anesthesia can be avoided in this procedure but the gas may cause considerable distress to the patient. Another drawback is that, repair of lesions or collection of tissue for lab tests is not possible in virtual colonoscopy. If abnormalities are detected, the patient may still have to undergo colonoscopy.
The patient is made to swallow a tiny capsule containing a tiny camera in a diagnostic procedure named capsule endoscopy. It is a procedure which has great diagnostic potential but there are several limitations which have to be addressed before it can become a popular test.
Diagnostic Tests: If abnormalities in the rectum are discovered while viewing it with a sigmoidoscope, or if blood is found in the stool, a more comprehensive diagnostic test called colonoscopy is conducted. It has the advantage that, if any lesions are found in the colon or the rectum during the test, they can be repaired. Also, biopsy of a tissue sample becomes possible.
When cancer of the colon and the rectum are detected, x-rays of the chest and abdomen are taken to check for metastases. CT scan of the abdomen also may be done. Routine blood tests are also done to assess the general condition of the patient and to check for anemia.
Colorectal cancer is not detected by blood tests. However, after the surgical removal of the cancerous growth, blood tests for certain markers help in assessing the chance of recurrence. Carcinoembryonic antigen or CEA, CA 125 and CA19-9 are cancer markers which are found in high levels when colorectal cancer starts developing again.
Prognosis and Treatment
Prognosis for people with colorectal cancer is good when the disease is detected in early stages and appropriate treatment is given. When the cancer is confined to the lining of the colon and the rectum, it can be cured by surgery in nearly 90% of the cases. If it has spread a little into the wall of the bowel, surgical removal of the affected part cures the disease in 70% of instances. The rate of survival significantly reduces to less than 50% when the cancer has invaded nearby lymph nodes. Once it has grown deep into the walls of the bowel, it may have crossed the stage for successful treatment. Even before metastases become apparent, the cancer cells may have taken root in other tissues and organs such as the liver.
After the cancer has spread, the chances of a complete cure are slim and the treatment is mainly aimed at the management of the disease. The treatment of cancer varies according to its spread. Surgical removal of the cancerous growth and the surrounding tissue is the first line of treatment, and the most effective, in curing cancer in the early stages. Often, the affected part of the colon or rectum is completely removed and the remaining pieces are stitched back together. Doctors may prefer to remove the lymph nodes also, to prevent the recurrence of cancer. In case the cancer has spread deep into the wall of the bowel, or to the lymph nodes, chemotherapy is given after the surgery. It may help prolong life by retarding the growth of cancer cells which may be remaining in the body. Radiotherapy also may be given to prevent the development of new tumors and to suppress the growth of existing ones. It is not a cure for the disease, but it may help prolong life to some extent.
For cancer of the rectum, in addition to the extent of its growth, its location is also taken into consideration while deciding on the surgical treatment. If the cancer is widespread, the rectum and the anus are completely removed. Another route is created for the excretion of feces. By a procedure called colostomy, the colon is directly attached to a specially created opening in the abdominal wall. The stool gets collected in a plastic bag attached to this opening, via a tube. The bag is emptied out periodically. Whenever possible, doctors try to save at least the lower part of the rectum and the anus so that the colon can be connected to the rectal stump. This avoids the hassle of colostomy and carrying around of the bag of stool.
The liver is usually the first organ to be affected by the metastasizing colorectal cancer because the portal vein collecting the nutrient rich blood from the intestines goes to the liver directly. When the colorectal cancer has metastasized into the liver, a small pump is used to deliver chemotherapy drugs into the hepatic artery for more effective treatment. An implantable pump can be fixed under the skin, or a pump can be worn externally, in this procedure called arterial hepatic chemotherapy. This treatment is beneficial only if the cancer has not spread to anywhere other than the liver.
Desiccation is a procedure for shrinking the tumors using either an electric current applied directly to them, or Argon gas which is electrified into plasma state. It will cauterize the cancerous growths and cause them to shrink and shrivel. The probes and devices used for these procedures are introduced into the colon and rectum with the help of a colonoscope. These minimally invasive procedures are generally used in people who are too old or too weak to undergo surgical removal of the colorectal cancer. However, desiccation is not a cure for the cancer. It is a temporary measure to provide relief from the symptoms of cancer and to prolong life by slowing down its growth.
If the cancer has metastasized widely, and if many lymph nodes and other organs are affected, surgery may not help, and the effect of chemotherapy or radiation therapy also may be limited. Chemotherapy using fluorouracil or another chemotherapy drug may be given but it may not help much in prolonging life. Sometimes, surgery may become necessary to remove obstruction in the colon or the rectum. When the cancer has reached this stage, the expected survival time is less than a year and death may occur in 6 to7 months. The main focus is in keeping the patient as comfortable as possible and in ensuring quality of life to the extent possible. At this stage, the doctor and the patient may have to discuss various options for palliative treatment, and end-of –life care, involving the patient’s family and caregivers in the discussion.
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What Are Colorectal Polyps
Colorectal polyps are fleshy outgrowths arising from the walls of the large intestine; they project into the colon and the rectum.
- Colorectal polyps may be hereditary
- Blood in the stool is the usual symptom
- Diagnosis is confirmed by colonoscopy
- Colorectal polyps can be removed surgically
The polyps, which are small fleshy projections of the intestinal wall found in the colon and rectum, are generally benign growths but they have the potential of developing into malignant tumors. They vary greatly in size and the larger polyps usually turn out to be cancerous. Some polyps may be precancerous with a higher chance of developing into malignant tumors if they are not removed. Some polyps may have a stalk or peduncle; they are usually benign. The polyps that grow without stalks and those consisting of glandular cells (adenomatous) are most likely cancerous. Precancerous adenomatous polyps eventually become adenomas, and among them, the serrated forms are aggressive in their growth.
Hereditary Conditions: Hereditary is a major contributing factor to colorectal polyps. Peutz-Jeghers syndrome and inherited familial adenomatous polyposis are two examples of the hereditary conditions predisposing certain people to colorectal polyps.
In the inherited condition called familial adenomatous polyposis, a large number of polyps develop in the rectum as well as in the large intestine, very early in life. These polyps eventually become malignant, resulting in colorectal cancer even before the person reaches the age of forty years. Those who have this hereditary condition are prone to developing Gardner’s syndrome. They develop noncancerous growths or tumors of different types in various parts of the body such as the skull, jaws and on the skin.
People who have Peutz Jeghers syndrome develop a large number of small polyps all along the digestive tract, starting from the stomach and all the way down to the rectum. Characteristic spots of blue-back color are also present on their limbs and faces and even inside their mouths. These marks on the skin may fade as the youngsters reach puberty but those inside the mouth remain. People who have this syndrome are highly prone to developing cancers elsewhere in the body too. The usual sites include the uterus, ovary, breast, and lungs in addition to parts of the digestive system such as the intestines and the pancreas.
Symptoms and Diagnosis
The colorectal polyps may remain asymptomatic or they may cause symptoms such as bleeding through the anus. When the polyp grows large, it can cause obstruction in the large intestine or the rectum. Abdominal cramps and pain may also be present. Occasionally, a polyp in the rectum with an elongated stalk may protrude out of the anus. Some polyps called villous adenomas, which have projections on them, may cause diarrhea as they keep excreting salts and water. Hypokalemia or low potassium levels in the blood may result from this continuous diarrhea.
Rectal polyps may be detected by the doctor while examining the rectum with a gloved finger. But diagnosis is usually done with a test called sigmoidoscopy, in which the rectum and part of the large intestine are examined with a flexible viewing tube. If polyps are detected in the rectum during a sigmoidoscopy, the large intestine is thoroughly examined by a more comprehensive test called colonoscopy. There is always a higher chance of finding more polyps and some may be cancerous too. During colonoscopy, a biopsy also can be done to detect the presence of cancerous polyps.
Treatment
The colorectal polyps have a very strong tendency to become malignant; hence, doctors prefer to remove all the colorectal polyps as soon as they are detected. They can be removed with a cutting tool attached to the colonoscope. An electrified wire loop may be used to remove pedunculated polyps, but major surgery may be needed to get rid of those polyps which are without stalk.
When malignant polyps are detected, biopsy is done to determine the exact nature of the cancerous growth. The surgically removed polyps are examined under the microscope to see whether the malignancy has affected the stalk of the polyp. If the stalk is affected, the portion of the large intestine where the polyp originated is also removed. Then the intestine is repaired by attaching the two severed sections together.
People who are diagnosed with colorectal polyps should undergo colonoscopy regularly, usually once a year, even after the existing polyps are surgically removed. Since there is a high probability of the condition recurring, the rectum and the large intestine are thoroughly checked for polyps during the test. Alternatively, barium enema test can also be done to get a clearer x-ray picture of the intestine and the rectum.
The treatment for those suffering from familial adenomatous polyposis involves the surgical removal of the large intestine to avoid the risk of the polyps developing into malignant tumors. The small intestine is then surgically attached to the rectum. The rectum is also prone to polyps, but after the removal of the large intestine, the occurrence of rectal polyps is found to be rarer. However, a sigmoidoscopy may have to be conducted at regular intervals of 3 months or 6 months to detect the development of polyps in the rectum. If they are found to be developing again, they are immediately removed. Sometimes, the rectum also may have to be removed if the polyps proliferate there. This situation makes an ileostomy inevitable. An opening is created on the abdominal wall, to which the small intestine is connected; thus forming an alternate route for excretion. A disposable or reusable plastic bag is attached to the opening, via a plastic tube, for the collection of feces.
When people with hereditary adenomatous polyposis were treated with certain NSAIDs, the colorectal polyps subsided, but the effect seemed to be reversible, as the polyps returned when the drug treatment was stopped. Research is still continuing in this direction, to find an effective cure for familial polyposis.
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Cancer Of The Small Intestine
Cancers may develop in the small intestine too, but they are not very common.
- The symptoms of cancer in the small intestine include bloody stools, abdominal cramps and vomiting. Occasionally the tumor may cause blockage in the intestine.
- Endoscopic examination and imaging tests like barium x-rays help in diagnosis.
- The cancerous tumors can be surgically removed.
Among the different types of cancer of the small intestine, adenocarcinomas are the most common. They originate from the glandular cells of the intestinal wall. Generally, malignant tumors in the small intestine are rare with less than six thousand people being affected by them every year in the US. However, those who have Crohn’s disease are at a higher risk of developing cancers of the small intestine, especially the adenocarcinomas.
Symptoms and Diagnosis
The malignant tumors in the small intestine may start bleeding, which results in the usual symptom of blood in the stool. When the cancerous tumors grow in size, they may cause obstruction in the small intestine. The symptoms of obstruction are usually abdominal cramps, vomiting and abdominal distension.
When a person comes with symptoms such as bloody stool, abdominal cramps and vomiting, the doctor may conduct a physical examination. If cancer of the upper part of the digestive tract is suspected, an upper endoscopy examination is conducted which helps to make an accurate diagnosis. The upper part of the intestine called duodenum and the middle portion jejunum can be viewed through a flexible endoscope which is inserted through the mouth. During the endoscopic examination, a biopsy of the tissue sample can be obtained for further tests. The last part of the intestine named ileum is accessed from the anus using a flexible viewing tube called colonoscope which is threaded through the large intestine into the ileum. An x-ray using radio opaque barium solution for contrast can also show the abnormal growths in the small intestine. In a diagnostic test called capsule endoscopy, the patient is given a capsule containing a tiny camera inside. As the capsule passes through the different portions of the digestive tract, it records and transmits the internal images so that all the abnormalities along the way can be detected.
In another imaging test called arteriography using radio opaque dye and x-ray, the dye is injected into the artery supplying the affected part, so that the abnormality may be shown clearly in the x-ray. This test is preferred to barium swallow when there is bleeding from the tumors. To detect the location and extent of bleeding, x-ray is taken after the injection of radioactive technetium into the artery so that the bleeding can be observed and surgically repaired. Occasionally surgery is required to locate the tumor, in such cases; excision of the tumor also is done at the same time.
Treatment
Surgery is the best option for malignant tumors of the small intestine. After the removal of the cancerous tumors, radiation as well as chemotherapy may be done but they do not have any significant role in prolonging life.
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Benign Tumors Of The Small Intestine
Different types of tumors may develop in the small intestine, but most of them are benign. Non cancerous tumors of the intestine may be classified by their origin as follows:
- Lipomas originating from fat cells
- Neurofibromas which develop from the nerve cells
- fibromas of the connective tissue
- leiomyomas which originate in the muscle cells
The benign tumors developing in the small intestine are usually asymptomatic. Occasionally, some tumors may start bleeding resulting in black tarry stools or melena. Large tumors may result in intestinal obstruction which may be partial or total. Intussusception is a dangerous condition that may develop, in which one part of the intestine gets pushed into its adjacent part as in a collapsing telescope. It results in intestinal strangulation, as the blood supply is cut off. This can be a life threatening condition which requires medical intervention at the earliest.
Minimally invasive procedures using an endoscope can destroy small tumors. Electrocautery by direct application of electric current, or thermal obliteration using direct heat on the noncancerous tumors, are two options for destroying them. In laser phototherapy high energy light is focused on the tumor to destroy the abnormal tissue. Larger tumors may have to be surgically removed to relieve the obstruction in the intestine
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What Is Stomach Cancer
Cancer of the stomach (Gastric Cancer) is a common occurrence; infections or inflammations of the stomach wall are the triggers which lead to the development of stomach cancer.
- Infection by the bacteria Helicobacter pylori is found to be the major cause of gastric cancer.
- The symptoms include discomfort or pain in the stomach, weakness and unexplained weight loss.
- endoscopic examination is the ideal tool for diagnosis of stomach cancer.
- When the cancer has already spread to other areas, rate of survival is very low.
- Cancerous growths in the stomach can be surgically removed to get relief from symptoms.
Adenocarcinomas are the most usual form of stomach cancer, constituting 95 % all of the cancers of the stomach. They develop in the glandular tissue lining the stomach.
The distribution of adenocarcinoma in the general population varies depending on age and race as well as socioeconomic and geographical conditions. American Indians, Hispanics, and blacks and those from lower income groups seem to be predisposed to stomach cancer. More than twenty thousand cases of adenocarcinoma are reported in the US every year though the incidence is on the decline now. It is more prevalent in people in the northern regions and those who are from certain countries such as China, Japan, Iceland and Chile. Stomach cancers commonly appear in people above the age of 50.
Causes and Risk Factors
Adenocarcinoma usually originates from a site of inflammation in the lining of the stomach. Injuries to the stomach lining may have caused the inflammation but the most common reason of stomach cancer has been found to be infections, particularly by the Helicobacter pylori bacteria.
Stomach polyps are usually harmless growths of the stomach wall projecting into the stomach cavity, but sometimes they may become precancerous and eventually develop into stomach cancer, especially when they consist of the glandular cells of the stomach wall. When many polyps exist together or when they are large in size, the chances of them becoming cancerous are higher.
Consuming processed foods and high carbohydrate diet, high salt intake, consuming foods containing preservative agents like nitrates, usually found in smoked items of food like meat, are suspected to increase the chances of developing stomach cancer. Likewise, diets poor in fruits and vegetables are also said to make people prone to stomach cancer, though there is no conclusive proof for the above assumptions.
Symptoms
The early symptoms of stomach or gastric cancer are not very obvious, and they usually resemble the symptoms of peptic ulcer such as pain and burning in the abdomen. In fact, the possibility of stomach cancer is often considered when symptoms of peptic ulcer do not seem to subside even after treatment. Early satiety, even with small amounts of food, is a usual symptom.
Other symptoms include unexplained weight loss and anemia. They may be a result of inadequate food intake, or malabsorption of nutrients and vitamins from the food. Anemia could be due to different reasons such as:
- loss of blood by the slow but steady bleeding from the affected region
- deficiency of Vitamin B12 necessary for the formation of red blood cells due to malabsorption
- deficiency of iron, which is the main constituent of the oxygen carrying molecule hemoglobin in the red blood cells, due to malabsorption.
People who develop anemia may have weakness, a light headed feeling and fatigue. The internal bleeding causes black stools called melena or it may result in a condition called hematemesis, characterized by bright red blood in the vomit.
.Adenocarcinoma metastasizes early and causes the cancer to spread to different areas elsewhere in the body. When it spreads to the liver, it causes enlargement of the liver and precipitates symptoms of jaundice such as yellowing of the eyes and skin. A condition called ascites, characterized by the accumulation of fluid and consequent bloating of the abdomen, also develops. As the disease progresses, cancerous nodules may appear on the skin and bones may become weak and easily fractured. When adenocarcinoma has grown large, it may be felt as a lump when doctor examines the abdominal region.
Diagnosis
An endoscopic examination of stomach with a flexible viewing tube is the ideal investigative procedure for diagnosing cancer of the stomach. The direct viewing of interiors of the stomach will help the doctor detect Helicobacter pylori infection. The endoscope can retrieve tissue samples for biopsy also. Another diagnostic test is Barium swallow, in which x-rays are taken, after the patient swallows a dose of radio opaque barium solution, which would show abnormal growths in the stomach. This test is not very accurate and not suitable for detecting the cancer in the initial stages.
Once the presence of cancer is confirmed, a CT scan of the abdomen and the chest is done to determine the exact location and size of the cancer. It can also detect the spread of cancer to other organs. Endoscopic ultrasound is another diagnostic procedure in which an ultrasound probe is attached to the endoscope inserted into the stomach. It gives a clearer picture of stomach walls and helps assess the depth and spread of the cancer. The involvement of lymph nodes in the area also can be determined.
Prognosis and Treatment
The prognosis is not bright for the long-term survival of patients, as more than 85% of those having stomach cancer succumb to the disease within a span of five years. This is mainly because of the early spread of cancer to other areas. Adenocarcinoma of the stomach which remains localized may be cured by surgical excision of the tumor. The affected part of the stomach and the lymph nodes in the surrounding area are also removed. In countries like Japan where routine screening for stomach cancer is done due to its high incidence, the prognosis and outcome of surgery are good because of early detection and treatment. In the US, the fatality rate is high because the cancer would have already penetrated deep into the stomach wall or it would have metastasized to other areas by the time it is detected. Treatment for stomach cancer may include radiation and chemotherapy in addition to surgery.
When the cancer has spread to other areas and it cannot be cured by surgery, the aim would be to retard the growth of the cancer as much as possible to prolong life and provide relief from distressing symptoms. Radiation and chemotherapy may help in keeping the growth of cancer under check for a while. If there is obstruction to the passage of food from the stomach into the intestine, the blocked area is bypassed by surgically attaching the intestine to a point before the block. It allows for the smooth passage food in the digestive tract, thus relieving pain and vomiting due to obstruction.
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Benign Tumors Of The Stomach
Many of the tumors developing in the stomach are benign or noncancerous in nature. As long as they remain asymptomatic, they are not usually diagnosed and no treatment is necessary. But when they start showing symptoms such as bleeding from the stomach, they may be surgically removed or by a minimally invasive procedure using an endoscope.
Some noncancerous abnormal growths projecting into cavity called stomach polyps may become precancerous with the potential of developing into cancer. Because of this, when polyps are detected in the stomach, they are removed by one of the following procedures.
- Electrocautery in which electrical current is used to destroy the polyps
- Thermal obliteration in which the polyps are destroyed using direct application of heat
- Laser phototherapy where high energy light is focused on the tumor to burn it off
These minimally invasive procedures are performed by an endoscope which is introduced into the stomach through the mouth and down the esophagus.
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What Is Esophageal Cancer
Some tumors developing in the esophagus may be cancerous in nature.
If diagnosed early enough, esophageal cancer can be treated with better outcome.
- Cancers of the esophagus generally originate from the lining of the esophageal wall.
- Inflammatory disorders of the esophagus, some infections, and tobacco usage and alcohol abuse, increase the risk of esophageal cancer.
- Dysphagia, pain and discomfort and weight loss are the usual symptoms.
- Endoscopy of the esophagus confirms the diagnosis of esophageal cancer.
- Fatality rate in people with esophageal is extremely high if the cancer is not detected early and treated appropriately.
- chemotherapy, radiotherapy, and surgery may provide relief from distressing symptoms and prolong life
There are different types of cancers affecting the esophagus. Some of the commonly occurring esophageal cancers are adenocarcinoma and squamous cell carcinoma originating from the lining of the esophageal wall. They can appear in different forms such as
- A stricture or narrowing of the esophageal passage
- A lump protruding into the esophagus
- A plaque or a flat area of tissue
- A fistula connecting the esophagus and the trachea or air pipe
Other types of cancer affecting the esophagus are leiomyosarcomas, lymphomas, rhabdomyosarcomas, malignant melanomas which occur less frequently. Cancers which have originated in other parts of the body may spread to the esophagus; it is termed as metastatic cancer.
The esophageal cancers vary in their distribution depending on racial group, gender and geographical region. While over fifteen thousand people are diagnosed with esophageal cancer in the United States every year, the incidence is higher in the United Kingdom and many Asian countries like china, India and Japan and countries surrounding the Caspian Sea.
In the United States, blacks are more affected by squamous cell carcinoma while the incidence of adenocarcinoma is more in whites. Both types occur more frequently in men than in women. Squamous cell carcinoma which occurs in the lower esophagus used to be more common earlier, but the incidence of adenocarcinoma, which generally affects the upper esophagus, is increasing faster.
Risk Factors
People who use alcohol and tobacco products are found to be more prone to esophageal cancers, especially squamous cell carcinomas. Those who already have other cancers in the neck or head are also predisposed to cancer of the esophagus. Some viral infections, such as by the human papilloma virus and radiation exposure are some of the other risk factors raising cancer risk.
Esophagus already damaged due to various reasons makes it more vulnerable to the development of cancer. In people who have GERD, the lining of the esophagus gets constantly irritated by the stomach acids which enter the esophagus with the reflux. This repeated exposure to acids result in a condition called Barrett’s esophagus which is often found to be a pre-cancerous stage of esophageal cancer. Ingestion of corrosive chemicals like strong alkalis and acids damage the lining of the esophagus and causes it to become narrowed and eventually develop cancer. Other disorders of the esophagus which cause difficulty in swallowing, such as the motility disorder achalasia, and the Plummer-Vinson syndrome characterized by webs in the esophagus, are also considered premalignant conditions as they increase the risk of cancer.
Symptoms
Esophageal cancer is asymptomatic in early stages, and due to this reason they often go undiagnosed at a time they can be treated better. Dysphagia is usually the first symptom of esophageal cancer; it happens due to the narrowing of the esophagus resulting from the growth of the cancer. Initially it may start as a difficulty in swallowing harder solid foods only, but this condition may deteriorate fast, and within weeks, swallowing of soft foods and eventually liquids and even saliva may become extremely difficult. Noticeable reduction in weight is another symptom, and patients may feel pain in the chest, and also the feeling that the pain is moving to the back of the chest.
With the progression of the esophageal cancer, other tissues, nerves and various other organs become affected by the spreading cancer growth. Voice may become hoarse due to the compression of the nerve regulating the vocal cords. Horner’s syndrome is another symptom that usually develops as the disease progresses, and it results in hiccups and spinal pain caused by the cancer pressing on the surrounding nerves. When the esophageal cancer spreads to the lungs, shortness breath may result and when liver is affected, symptoms like bloating of the abdomen and pain may appear. When it starts affecting the intestines, it can cause vomiting, bloody stools, and anemia resulting from blood loss. Confusion, headaches and even seizure may occur if the cancer metastasizes to the brain. Complete blockage of the esophagus develops in the later stages of the cancer and drooling from the mouth is common resulting from the inability to swallow even saliva. The later stages of the disease cause severe distress and weakness and medical intervention is unavoidable during this time.
Diagnosis
Endoscopic viewing of the esophagus is the diagnostic test of choice, for suspected cases of esophageal cancer. The endoscope is a flexible tube which is inserted into the esophagus through the mouth so that the interiors of the esophagus can be observed. Biopsy sample of the esophageal tissue also can be extracted during the endoscopic procedure.
Barium swallow, followed by X-ray imaging, is another diagnostic tool used to determine the location and size of the tumor. During this procedure, the patient is given the radio opaque barium solution to swallow, which would show up on the X-ray taken immediately afterwards, showing the abnormalities in the esophageal lining.
Ultrasonography scan with the scanning probe inserted into the esophagus with the help of an endoscope is also done sometimes. CT scan is another diagnostic option which can provide accurate details about the tumor.
Prognosis and Treatment
The prognosis for people with esophageal cancer is not very bright, mainly because of late diagnosis. Consequently, fatality rates are high, most of those diagnosed with the condition dying within a year from the onset of symptoms. Survival rate beyond 5 years is as low as 5%. Because of the almost certain fatal outcome, the focus of treatment is ensuring quality of life while trying to slow down the pace of progression of the disease. Dysphagia and odynophagia (pain while swallowing) are both highly distressing conditions for the patient as well as the caregivers. Through various medical procedures and drug treatments, doctors try to reduce the symptoms and help maintain normalcy for as long as possible.
Surgical removal of the cancerous tissue is the most effective treatment which can greatly relieve the symptoms like dysphagia and odynophagia. However, surgery does not cure the cancer if it has become widespread. Chemotherapy may destroy some of the cancer cells and can retard the progress of the disease. Combined with radiation therapy, it can help prolong life, if only for a few months. Radiotherapy and chemotherapy are usually done prior to surgery to increase the chances of a better outcome.
To make swallowing easier, the portion of the esophagus narrowed due to the cancer may be dilated and a stent may be fitted to keep it open. The cancer affected area can be bypassed using a portion of the intestine, thus providing an alternate route for the passage of food. The cancerous tumors growing into the esophagus can be destroyed by laser phototherapy in which high energy light is used to incinerate the cancer tissue and open up the esophageal passage. These measures taken to widen the esophagus give temporary relief from the symptoms, but they do not help in arresting the growth of the cancers.
Photodynamic therapy is a very effective procedure in relieving symptoms and it is the ideal treatment for people too weak to undergo surgery. It can destroy esophageal lesions and other obstructing tissues much faster than the other treatments such as radiation therapy as well as chemotherapy. In this procedure, a dye which is sensitive to light is administered intravenously two days prior to the procedure. The cancer cells absorb more quantity of the dye compared to the healthy cells. When the laser light is focused on the affected area, the dye in the cancer cells causes their destruction while the surrounding healthy tissue is spared.
The role of nutrition in keeping the patient strong enough to tolerate the treatment procedures is very important. If the patient is on liquid foods, food supplements in concentrated form should be incorporated into diet. Intravenous supplementation or tube feeding may have to be established for those patients who cannot swallow even liquid food.
The outcome of esophageal cancer being extremely poor, especially when it is diagnosed late, the patient should be helped to put his affairs in order and may be to prepare his will. The patient should be advised about the choices available for end- of- life care and should be encouraged to express his choice regarding continuing medical care.